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Conjugated Hyperbilirubinemia Clinical Presentation

  • Author: Richard A Weisiger, MD, PhD; Chief Editor: BS Anand, MD  more...
 
Updated: Jan 05, 2016
 

History

Clinical evaluation of those with suspected conjugated hyperbilirubinemia always starts with obtaining a full history.

Potential toxins (eg, drugs), environmental chemicals (eg, solvents), or wild mushrooms must be carefully excluded. Failure to promptly diagnose toxic hepatitis may result in hepatic failure and death.

Risk factors for viral hepatitis should be elicited. Possible risk factors include the following:

  • Transfusion
  • Intravenous (IV) drug use
  • Multiple sexual partners
  • Exposure to a person who is infected

Also note the following:

  • Colicky abdominal pain or fever suggests gallstone disease.
  • Weight loss or constitutional systems suggests malignancy or chronic infection.
  • Recent anesthesia with the use of halothane suggests halothane hepatitis.
  • A history of intense pruritus suggests cholestatic disease resulting from biliary obstruction or intrahepatic cholestasis.
  • A family history of jaundice suggests inborn errors of bilirubin metabolism.
  • In patients with severe intercurrent illnesses, consider sepsis, hepatic ischemia, and opportunistic infections.
  • Severe right heart failure or tricuspid insufficiency with hepatomegaly suggests hepatic congestion.
  • Patients on parenteral nutrition may experience cholestasis that sometimes improves with the addition of lipid infusions.
  • Patients with acquired immunodeficiency syndrome (AIDS) may experience biliary obstruction from opportunistic infections (eg, AIDS cholangiopathy).
  • Patients with chronic liver disease may experience transient elevation of their bilirubin levels following blood transfusion, which results due to a more rapid turnover of the infused cells.
  • In patients younger than 20-25 years, a history of a recent flulike syndrome treated with aspirin raises the possibility of Reye syndrome.
  • Pregnancy suggests benign recurrent cholestasis or, in late pregnancy, acute fatty liver of pregnancy.
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Physical Examination

The first manifestation in cases of conjugated hyperbilirubinemia is commonly a brownish discoloration of the urine. Although scleral icterus may also be present, this typically reflects the unconjugated fraction of bilirubin that binds tissues much more avidly.

If sufficient unconjugated bilirubin is present, the skin, sclerae, and mucous membranes take on a yellow color, although this may be difficult to detect if the tissues are pigmented naturally.

Depending on the underlying illness, stigmata of chronic liver disease may or may not be present.

Palpation of the abdomen may reveal the following:

  • A mass (eg, a distended gallbladder, abdominal tumors)
  • Tenderness over the liver (eg, as in cases of hepatitis or hepatic distention resulting from congestion or infiltrative disease)
  • Tenderness over the gallbladder fossa (as occurs in cases of biliary disease or infection)

In cases of biliary obstruction or stasis, stool may be acholic and light gray.

Unexplained darkening of the skin, diabetes, or heart failure suggests hemochromatosis.

Kaiser-Fleisher rings (accompanied with a low serum ceruloplasmin concentration) suggests Wilson disease.

Cutaneous or neurologic findings of chronic alcoholism may be helpful diagnostic findings.

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Contributor Information and Disclosures
Author

Richard A Weisiger, MD, PhD Emeritus Professor, Department of Internal Medicine, University of California, San Francisco, School of Medicine

Richard A Weisiger, MD, PhD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Society for Clinical Investigation

Disclosure: Nothing to disclose.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgements

Vivek V Gumaste, MD Associate Professor of Medicine, Mount Sinai School of Medicine of New York University; Adjunct Clinical Assistant, Mount Sinai Hospital; Director, Division of Gastroenterology, City Hospital Center at Elmhurst; Program Director of GI Fellowship (Independent Program); Regional Director of Gastroenterology, Queens Health Network

Vivek V Gumaste, MD is a member of the following medical societies: American College of Gastroenterology and American Gastroenterological Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
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  2. Muraca M, Fevery J, Blanckaert N. Analytic aspects and clinical interpretation of serum bilirubins. Semin Liver Dis. 1988 May. 8(2):137-47. [Medline].

  3. Westwood A. The analysis of bilirubin in serum. Ann Clin Biochem. 1991 Mar. 28 ( Pt 2):119-30. [Medline].

  4. Iyanagi T, Emi Y, Ikushiro S. Biochemical and molecular aspects of genetic disorders of bilirubin metabolism. Biochim Biophys Acta. 1998 Sep 30. 1407(3):173-84. [Medline].

  5. Gottesman LE, Del Vecchio MT, Aronoff SC. Etiologies of conjugated hyperbilirubinemia in infancy: a systematic review of 1692 subjects. BMC Pediatr. 2015 Nov 20. 15 (1):192. [Medline].

  6. Klein CJ, Revenis M, Kusenda C, Scavo L. Parenteral nutrition-associated conjugated hyperbilirubinemia in hospitalized infants. J Am Diet Assoc. 2010 Nov. 110(11):1684-95. [Medline].

  7. Johnston DE. Special considerations in interpreting liver function tests. Am Fam Physician. 1999 Apr 15. 59(8):2223-30. [Medline].

  8. Segal I, Rassekh SR, Bond MC, Senger C, Schreiber RA. Abnormal liver transaminases and conjugated hyperbilirubinemia at presentation of acute lymphoblastic leukemia. Pediatr Blood Cancer. 2010 Sep. 55(3):434-9. [Medline].

  9. Gotze T, Blessing H, Grillhosl C, Gerner P, Hoerning A. Neonatal cholestasis - differential diagnoses, current diagnostic procedures, and treatment. Front Pediatr. 2015. 3:43. [Medline].

  10. Dani C, Pratesi S, Raimondi F, Romagnoli C, for the Task Force for Hyperbilirubinemia of the Italian Society of Neonatology. Italian guidelines for the management and treatment of neonatal cholestasis. Ital J Pediatr. 2015 Oct 1. 41:69. [Medline].

  11. Devgun MS, Chan MK, El-Nujumi AM, Abara R, Armbruster D, Adeli K. Clinical decision limits for interpretation of direct bilirubin--a CALIPER study of healthy multiethnic children and case report reviews. Clin Biochem. 2015 Jan. 48 (1-2):93-6. [Medline].

  12. Talachian E, Bidari A, Mehrazma M, Nick-khah N. Biopsy-driven diagnosis in infants with cholestatic jaundice in Iran. World J Gastroenterol. 2014 Jan 28. 20 (4):1048-53. [Medline].

  13. Memon N, Weinberger BI, Hegyi T, Aleksunes LM. Inherited disorders of bilirubin clearance. Pediatr Res. 2015 Nov 23. [Medline].

  14. van Dijk R, Beuers U, Bosma PJ. Gene replacement therapy for genetic hepatocellular jaundice. Clin Rev Allergy Immunol. 2015 Jun. 48 (2-3):243-53. [Medline].

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Gross liver specimen from a patient with Dubin-Johnson syndrome showing multiple areas of dark pigmentation. Image courtesy of Cirilo Sotelo-Avila, MD.
Microscopic histology of the liver in Dubin-Johnson syndrome showing multiple areas of granulated pigment. Fontana Mason stain. Image courtesy of Cirilo Sotelo-Avila, MD.
Liver biopsy specimen showing ground-glass appearance of hepatocytes in a patient with hepatitis B.
Plain abdominal radiograph in a patient with a clinical diagnosis of acute cholecystitis. The diagnosis was confirmed by means of abdominal ultrasonography. The radiograph shows faint opacities in the region of the gallbladder fossa and dilated loops of small bowel in the epigastrium and midabdomen secondary to localized ileus.
A 26-year-old man known to be human immunodeficiency virus (HIV) positive presented with pain in the right upper quadrant and mild jaundice. Axial sonogram through the gallbladder (GB) and pancreas (P) shows sludge within the gallbladder and the lower common bile duct (arrow). A diagnosis of acalculous cholecystitis was confirmed. A = aorta; IVC = inferior vena cava; S = splenic vein.
Table. Differential Diagnosis of Conjugated Hyperbilirubinemia
I. Acute or Chronic Hepatocellular Dysfunction II. Diseases That Prevent Flow of Bile into the Intestine
A. InfectionA. Damage to Intrahepatic Bile Ducts or Portal Tracts
Viral hepatitis A-E



Cytomegalovirus (CMV) hepatitis



Epstein-Barr virus hepatitis



Sepsis



Primary biliary cirrhosis



Graft versus host disease



Veno-occlusive disease



Sclerosing cholangitis



B. Inflammation Without InfectionB. Damage to or Obstruction of Larger Bile Ducts
Toxic liver injury



Drug toxicity (eg, acetaminophen)



Halothane hepatitis



Alcoholic hepatitis



Iron overload (hemochromatosis)



Copper overload (Wilson disease)



Autoimmune hepatitis



Choledocholithiasis



Sclerosing cholangitis



AIDS cholangiopathy



Hepatic arterial chemotherapy



Postsurgical strictures



Bile duct cancers



Developmental disorders of the bile ducts (eg, Caroli)



Extrinsic compression of the bile duct



Tumors



Acute pancreatitis



C. Metabolic DysfunctionC. Diffuse Infiltrative Diseases
Ischemia ("shock liver")



Acute fatty liver of pregnancy



Alpha-1 antitrypsin deficiency



Preeclampsia



Reye syndrome



Total parenteral nutrition



Granulomatous diseases



Sarcoidosis



Disseminated mycobacterial infections



Lymphoma



Wegener granulomatosis



Amyloidosis



Diffuse malignancy



D. Inborn Errors of MetabolismD. Diseases That Interfere with Biliary Secretion of Bilirubin
Dubin-Johnson syndrome



Rotor syndrome



Benign recurrent cholestasis



Drug-induced cholestasis, as with the following:



- Chlorpromazine



- Erythromycin



- Estrogens



- Anabolic steroids



- Many others



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